1.4.35 West Yorkshire Safer Sleep Protocol Guidance: for professionals working with families where there is a child aged up to 12 months

1. Introduction

This guidance is applicable to the multi-agency workforce (MAW) that has contact with parents, carers and their wider support network. It is to assist practitioners to discuss safer sleeping arrangements in order to support parents to make informed decisions regarding safer sleep and raise awareness to risk factors associated with Sudden Unexplained Death in Infancy and Childhood (SUDI/C).

The purpose of this guidance is to:

Provide the multi-disciplinary workforce in West Yorkshire with clear and consistent evidence-based information;
Provide workers with the confidence and knowledge to facilitate an open and honest discussion to support parents and carers to make informed safer sleeping decisions for their babies and young children;
Ensure that consistent advice about safer sleeping arrangements is given across West Yorkshire by all workers;
Ensure staff who visit households understand what constitutes an unsafe sleeping environment/practice, and what support services they can access for the parents/care givers and their support networks;
Ensure staff who have contact with families can identify babies and young children who may be at greater risk of being in an unsafe sleep situation;
To embed SUDIC prevention and safer sleep within local safeguarding practice and wider strategies that support families in adverse circumstances;
To reduce the number of infants and young children in unsafe sleep situations;
To reduce the death rate of infants and young children in West Yorkshire.

The guidance presents evidence on a wide range of potential risk factors and family circumstances that are associated with sudden infant death syndrome (SIDS). Although SIDS rates have declined over the last 10 years, there is evidence of widening health inequalities with rates of SIDS being highest in the most deprived areas (The Lullaby Trust, 2018).

The Child Safeguarding Practice Review Panel ‘Out of Routine’ report (2020) summarised evidence from 40 infant death cases, highlighting that not only do these deaths now cluster among families from deprived socioeconomic circumstances, increasingly many of the families at risk for SUDI were also at risk for a host of other adverse outcomes, including child abuse and neglect.

Currently, in the UK more than one in five people live in poverty and half of these are children. Out of these five, four in ten are in very deep poverty (Joseph Rowntree Foundation 2024)

Infants appear to be more vulnerable to SUDI where families are under stress – with links to mental ill health, substance misuse, overcrowding, young parents, changes to family circumstances, deprivation, domestic abuse, excessive tiredness, poor engagement with services and involvement of children's services, demonstrating that safer sleep is not just the business of the childcare workforce: it is everyone's responsibility. The Out of Routine report encouraged a multiagency workforce approach to SUDI prevention and for it not to just be seen as the responsibility of health professionals.

Evidence also suggests that, in many cases, families who experience these tragedies are already known to children's services and/or safeguarding teams (Garstang and Sidebotham, 2018) and are aware of the safer sleep messages but are unwilling or unable to follow the advice (National Child Safeguarding Practice Review Panel, 2020). This document therefore discusses how safer sleep messages are communicated to families in a way that changes behaviour see Section 5, Having Effective Safer Sleep Conversations.

Furthermore, The National Child Mortality Database (NCMD) analysed the deaths of 10,256 children between 1st April 2019 and 31st March 2023 and found temporary accommodation was deemed to be contributing factor in the deaths of 55 children. Of those 55 children, 42 were less than a year old Exclusive: 55 homeless children have died in Temporary Accommodation since 2019 - Shared Health Foundation.

In June 2024 the Department for Levelling Up, Housing and Communities (DLUHC) changed the Homelessness Code of Guidance for councils to encourage the provision of cots, and has written to all local authorities saying they need to “make it explicit that temporary accommodation should not be considered suitable for a family with children under two if there is not enough space for a cot, and that housing authorities should support families to secure a cot where needed.” Homelessness code of guidance for local authorities - Guidance - GOV.UK (www.gov.uk).

2. Definitions

For the purpose of this document the following definitions will apply:

Sudden Unexpected Death in Infancy (SUDI)
‘Sudden Unexpected Death in Infancy is the term used for the sudden and unexpected death of a baby under 12 months. Deaths that remain unexplained after post mortem are usually registered as ‘sudden infant death syndrome’ (SIDS).

Sudden Infant Death Syndrome (SIDS)
Sudden infant death syndrome (formerly known as cot death) is defined as the sudden unexpected death of an infant less than 1 year of age, with onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including the performance of a complete autopsy and a review of the circumstances of death and clinical history (Krous, 2004 taken from NICE, 2014).

Other fatal sleep accidents
These deaths are similarly sudden and unexpected, but unlike SIDS may have a cause assigned, such as suffocation or strangulation in bed in the context of bed-sharing or unsafe items in the sleep environment. The distinction between SIDS and a sleep-related accident can be unclear even after investigation, but the risk factors are the same.

Overlaying
Rolling onto an infant and smothering them in bed or on a chair, sofa or beanbag.

Deaths in infancy
Term relates to deaths of babies under the age of one year.

Sleep positioners
A mat or cushion with raised supports or pillows attached to each side, designed to keep babies in a specific position when sleeping.

Pods, nests or hammocks
Sleep surfaces with raised or cushioned areas.

Bouncers
A padded seat or cradle with a bouncing and/or vibrating/rocking feature.

Baby's carer
A parent, grandparent, foster carer/s babysitter or any other person responsible for the baby at that particular time, for example a childminder or nursery setting.

Support network
A person or group of people who provide emotional and practical help.

Multi-disciplinary workforce
Anyone working in West Yorkshire coming into contact with families who reside in West Yorkshire.

Co-sleeping definitions

Co-sleeping
An umbrella term used to describe when parents or carers share the same sleep surface as the baby, this can be in a bed, on a mattress, on a sofa or in a chair. Some parents may refer to a next-to-me crib as ‘co-sleeping’, however this is not sharing the same sleep surface.

Room sharing
When a baby sleeps in the same room as their parent(s) or carer in a cot or Moses basket. This can include a next to me crib as this is a separate sleep surface.

Bed-sharing
When a baby shares the same bed with an adult for most of the night, and not just to be comforted or fed.

Sofa-sharing
When a parent or carer sleeps on a sofa or armchair with a baby, this is very dangerous and carries a significant (50-fold) increased risk of SUDI.

3. Background

Around 300 babies and young children die suddenly and unexpectedly in England and Wales each year. Since the ‘Back to Sleep’ campaign in the 1990’s, the number of infants dying of SIDS has fallen significantly. Yet, on average 3 babies die of SIDS every week in the UK. In 2021, 182 babies died of SIDS in England and Wales (Office for National Statistics (ONS).

Regional data for the North-West, Yorkshire & The Humber have shown deaths in our region are among the highest in the UK. Between 2007 and 2019 SIDS claimed the lives of 347 babies in Yorkshire and the Humber (Lullaby Trust).

Previous UK data suggests (UNICEF, 2022):

Around half of SIDS babies die while sleeping in a cot or Moses basket;
Around half of SIDS babies die while co-sleeping. However, 90% of these babies die in hazardous situations which are largely preventable;
63% of these deaths occur in male infants.

Although the cause of SIDS is not known, there are specific factors that make SIDS more likely (Lullaby Trust, 2024). Safer sleep messages can appear complex, controversial and at odds to the reality of parenting. However, it is important that family-centred communication is provided in order to ensure all parents and carers have access to clear and consistent information on how to reduce the risks of SIDS. If safer sleep advice is followed, it is possible some babies' lives could be saved.

4. Current Evidence-Based Information to be Provided to All Babies Carers

Since we do not know what causes SIDS, there is no advice that guarantees the prevention, but it is possible to reduce the risk. SIDS may be better understood if the focus on risk factors is complemented by a deeper appreciation of the protective resources that human infants acquire during their normal development (Renz-Polster et al 2024).

Every sleep needs to be a safer sleep – whether baby is sleeping at night, or during the day, at home or away from home. Therefore, safer sleep advice should be given to all who care for a baby within the family and wider support group. It is likely that new parents will seek advice from their wider family, and it is important that key figures are aware of safer sleeping information.

The current safer sleep campaign (correct as of March 2024) has been developed by Lullaby Trust, Public Health England (PHE), Basis and UNICEF and focuses on 6 key pieces of advice.

All staff and volunteers working with families should be aware of the following key pieces of evidence-based advice. The number of babies who die of SIDS could be reduced dramatically if families:

Put babies on their BACK to sleep in the FEET TO FOOT position in their cot for every sleep;
Place babies in a CLEAR, FLAT SLEEP SPACE, there should be NO pillows, quilts, duvets, soft toys, sleep positioners or cot bumpers;
Use a FIRM and FLAT mattress. If baby is asleep in a car seat or pushchair, move them onto a firm, flat surface at the earliest opportunity;
Keep their environment SMOKE FREE day and night;
Don't cover your baby's face or head while sleeping or use loose bedding;
Avoid letting your baby get too hot. A room temperature of 16–20ºC is recommended to avoid your baby overheating;
Keep your baby smoke free during pregnancy and after birth;
Breastfeed your baby as research shows that breastfeeding affords some protection against SIDS. Breastfeeding for at least 2 months halves the risk (Lullaby Trust );
Sleep your baby in the same room as you for at LEAST SIX months, DAY AND NIGHT.

Whilst they are sleeping, babies should always be in the same room as a parent/carer for ‘at least’ the first 6 months, day and night. This doesn’t mean you can’t leave the room to make a cup of tea or go to the toilet, but they are safest if you are close by. It is possible that parental movement/noise preserves the baby’s arousal mechanism and protects against SIDS. Use of baby monitors is not an alternative to this advice. The Lullaby Trust advises that despite widespread use of monitors by parents there is no research evidence that these prevent SIDS, and babies are known to have died whilst on a monitor. There have been no large scale studies looking specifically at the effect of monitor use on infant mortality rates.

Cardboard boxes should not be promoted as a safe sleeping space but only as a temporary substitute if nothing else is available. There is no evidence that they are a safe alternative to more traditional cots, bassinets or moses baskets and have safety implications (Blair and colleagues 2018). Lullaby Trust concluded that there is no evidence that they reduce infant deaths.

It is most important to explain that around half of all parents will sleep with their baby at some point, be this planned or unplanned, and although SIDS is very rare it is much more likely to happen in certain circumstances. If no baby co-slept in hazardous situations, we could potentially reduce co-sleeping deaths by nearly 90% (UNICEF, 2022).

Parents should be advised:

Never to sleep on a sofa or in an armchair with their baby;
Don't sleep in the same bed as your baby if:
- Either you or your partner smoke (even if not in the bedroom), or if the mother smoked during pregnancy;
- Either you or your partner has recently drunk alcohol;
- Either you or your partner has recently taken drugs (including medications that make you drowsy);
- Your baby was born prematurely (37 weeks or less);
- Your baby was of low birth weight (2.5kg (5 ½ lbs) or less).

Existing evidence does not support the conclusion that bedsharing among breastfeeding infants causes SIDS in the absence of known hazards (Blair et al 2019). Parents who choose to co-sleep in a parental bed, where the above risks do not apply, should be aware of steps they can take to make it safer:

Keep your baby away from the pillows;
Make sure your baby cannot fall out of bed or become trapped between the bedframe and headboard, the mattress and wall, or the gap between a next-to-me crib and the parental mattress;
Make sure the bedclothes cannot cover your baby's face or head;
Keep other children and pets out of the bed;
Don't leave your baby alone in the bed, as even very young babies can wriggle into a dangerous position (UNICEF, 2022);
The mattress needs to be firm and flat with no dips. An airbed is not a suitable alternative to a bed;
Breastfeeding mothers tend to adopt the ‘protective C’ position also known as the ‘cuddle curl’ keeping the infant at breast level and preventing her rolling onto the baby;
Follow all Lullaby Trust safer sleep advice such as sleeping baby on their back.

Equality and diversity considerations

Parents should be given information that they can easily access and understand themselves, or with support, so they can communicate effectively with healthcare services. Clear language should be used, and the content and delivery of information should be tailored to individual needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate. People should have access to an interpreter or advocate if needed. The interpreter or advocate should not be a member of the woman's family, her legal guardian, or her partner, and they should communicate with the woman in her preferred language. For parents with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.

5. Having Effective Safer Sleep Conversations

National advice on reducing the risk of SIDS and other fatal sleep accidents has been clear and consistent over many years. A national review into SUDI in families where the children are considered at risk of significant harm noted that while there is no evidence that this advice is not given routinely, it is not, for whatever reason, clearly received or acted on by some of those families most at risk (National Child Safeguarding Practice Review Panel, 2020). It is important therefore to reflect on how safer sleep messages are communicated to all families.

Evidence shows that interventions are most effective when they are personalised, culturally sensitive, enabling, empowering, relationship building, interactive, accepting of parental perspective, non-judgemental and are delivered over time (National Child Safeguarding Practice Review Panel, 2020).

Motivational Interviewing (Miller and Rollnick 2013) and a technique called EPE (Elicit, Provide, Elicit) can be useful when having effective safer sleep conversations. Elicit-provide-elicit (EPE) is a three-step technique used in motivational interviewing to share information with clients:

Elicit: Ask the client about their existing knowledge, beliefs, and interests on the topic;
Provide: Share relevant, accurate information in a clear, concise, non-judgemental way;
Elicit: Ask the client for their reaction, feedback, and questions about the information.

The Lullaby Trust identifies the following principles that should be applied when discussing safer sleep with families. These principles are also reflected in the NICE guidance on behaviour change.

Be open and non-judgemental

Creating an environment where families can discuss their situations and concerns without fear of judgement is crucial.

Focus on assessing needs rather than making assumptions. For example, breastfeeding families are not automatically 'safer' co-sleepers, and neither are formula fed babies always at a much higher risk (Lullaby Trust). Both groups need guidance that's tailored to their needs.

Shock messages that increase fear do not work. For example, shocking messages that imply that all/any co-sleeping leads to death are not helpful. They do not reflect the evidence, and they frighten parents and staff, induce guilt and close down honest conversations (UNICEF, 2022).

Explore

A relationship-based approach – developing supportive yet challenging relationships – can facilitate more effective safer sleep conversations. Parents are more likely to act on advice from someone they trust and believe.

Safer sleep conversations and advice should be tailored to each family's needs. Take time to understand the family's experiences and circumstances. What is influencing the family's sleep practices?

Conversations should combine empathy and support with appropriate challenge. Do not be afraid to tell families if their circumstances mean their baby is at higher risk.

Remember that it isn't helpful to tell parents what they must or mustn't do; instead, listen carefully and offer information appropriate to their needs (UNICEF, 2022).

Plan

It may be necessary to focus safer sleep conversations and information on risky situations, and to initiate 'what if' discussions about arrangements to ensure a safer sleep environment. Every family needs a plan to avoid potentially hazardous sleep situations on those occasions when something different happens.

For example, questions could include: what's happening tonight? Having a drink? Going on holiday or staying with friends? Letting your partner sleep? What's the family's plan if baby is unwell?

For further information please visit the Guidance and Tools to support families to plan for safe sleep or out of routine situations.

Explain

We know from research and discussions with parents that they are much more likely to follow advice if they understand the reason. The parent tool can offer clear advice.

It might be helpful to some families to explain normal baby behaviour and discuss expectations. Acknowledge that young babies wake and feed frequently in the night and that this is normal and not modifiable, as young babies are not capable of 'learning' to defer their needs. Accepting this reality can be helpful, as parents are reassured that their baby is normal, and they aren't doing anything wrong. It can also relieve the pressure to find 'solutions' (UNICEF, 2022).

Give clear advice

Information must be provided in such a manner that it is understood by the baby's carer. For those babies' whose carers do not understand English, an approved interpreter should be used where possible and appropriate. Families with other language and communication needs, including learning disabilities, should be offered information in such a way to aid understanding. See Section 10, Resources and Links.

Further information:

6. Risk Factors and Reducing the Risk

It is important to acknowledge that we don't always know why something presents as a risk factor to SIDS, only that the research conducted over a number of years tells us that certain circumstances are associated with an increased risk of SIDS.

The following chapter presents a summary of evidence on risk and protective factors associated with SIDS, divided into the following sections:

Factors associated with an increased risk of SIDS;
Factors associated with a decreased risk of SIDS;
Family circumstances associated with SIDS.

Evidence presented in The Lullaby Trust, Evidence Base has been summarised with additional information taken from literature reviews.

This evidence will inform the actions that Local Safeguarding Children Partnerships and their partner agencies will undertake to reduce the number of babies and infants in unsafe sleep situations.

Factors associated with an increased risk of SIDS

6.1 Sleep Position

Placing an infant to sleep on their stomach (prone) or side is significantly associated with an increased risk of SIDS.

Infants who usually sleep on their back (supine) but are unusually placed on the front (prone) or side are at increased risk of SIDS.

Prone and side sleeping is particularly dangerous for babies born with low birth weight, both those born preterm (before 37 weeks) and those with intrauterine growth restriction. Premature babies are sometimes slept on their front in hospital for special medical reasons. When they are getting ready to go home these babies should always sleep on their back to reduce the risk of sudden infant death (The Lullaby Trust - Safer Sleep Advice (lullabytrust.org.uk)).

There is no evidence that placing healthy babies on their back to sleep puts them at greater risk of death through aspiration of vomit and choking.

Parents/carers concerned about head deformities such as plagiocephaly (asymmetric flattening of the infant skull) may resort to non-supine sleep positions or use pillows marketed as preventative aids, despite both being risk factors for SIDS. The NHS provides guidance on what carers can do to take the pressure off the back of their babies head Plagiocephaly and brachycephaly (flat head syndrome) - NHS (www.nhs.uk).

As babies get older the sleep position cannot be controlled, as they will move to find the sleep position they find most comfortable.

Recommendations

Parents should be advised that placing an infant to sleep on their stomach or side is significantly associated with an increased risk of SIDS. The risk is further increased in babies who are either pre-term, low birth weight or those with intrauterine growth restriction;
Infants should always be placed on their back to sleep at the start of every sleep period, day or night;
It is important that babies are put on their backs consistently as part of their regular sleep routine;
Babies should be allowed supervised time in the prone position (tummy-time) when awake to avoid development of plagiocephaly and aid motor development.

Resources

The Lullaby Trust, The best sleeping position for your baby;
The Lullaby Trust, Reducing the risk of SIDS for premature babies.

6.2 Smoking and Vaping

Smoking

Maternal smoking both during pregnancy and after the baby is born increases the risk of SIDS. The risk appears to be dose related: the more cigarettes smoked, the higher the risk of SIDS.

The risk of SIDS is greatly increased in association with a combination of co-sleeping and smoking by either parent, even if they do not smoke in the bed.

Babies who grow up in a smoky atmosphere have an increased risk of SIDS. A smoky environment is anywhere near someone who is smoking, or in a room where someone has smoked.

Recommendations

Parents should not smoke during pregnancy or after birth; this applies to both parents;
Co-sleeping in a parental bed is unsafe if either parent smokes or the mother has smoked in pregnancy. Falling asleep on a sofa or in an armchair with a baby is always unsafe;
Postnatal exposure to second-hand smoke also puts a baby at risk; therefore it is important to keep a baby out of smoky atmospheres at all times, including sleeping;
Remind parent/carers that nicotine or smoke will not be visible, but does remain on clothes, in hair, carpets and sofas (third-hand smoke), for hours and or even days after a cigarette is extinguished;
Should people continue to smoke, advise on how to do this more safely or change smoking habits: ensure the environment is a smoke-free zone and people smoke outside. However, this does not change the bed sharing advice above. Remember it is illegal to smoke in a car or other vehicle with any children under 18 present.

At the first (booking) appointment with the midwife, pregnant women are asked their smoking status. If they are a smoker they are automatically referred to the smoking cessation service currently provided by Yorkshire Smoke Free. If this referral is declined, women can be referred to this service at any time in pregnancy and after birth. Partners and significant others can also self-refer.

Referral can be via any of the following routes:

NHS Stop Smoking Service - Yorkshire Smokefree;
Tel: 0800 612 0011 or 0330 660 1166;
Text: ’YSF’ to 80800.

Healthcare professionals can also refer their patients with consent. Referral forms are on SystmOne and E-MIS.

See: The Lullaby Trust, Smoking during pregnancy or after birth increases the risk of SIDS.

Vaping and e-cigarettes

There is no evidence yet relating to electronic ('e') cigarettes (vapes) and the risk of SIDS although it is hoped that these may be safer than standard tobacco cigarettes. The Smoking in Pregnancy Challenge Group recommends that pregnant women who find using an e-cigarette helps them to remain smoke-free should not be discouraged from doing so. The safest option is to stop smoking but if parents are unable to do this then e-cigarettes may be safer in pregnancy and after birth by reducing exposure to smoke.

As there is no direct research on using e cigarettes (vapes) and SIDS, it is recommended that parents do not co-sleep with baby if they use e-cigarettes or vapes.

Resources

6.3 Co-sleeping and Bedsharing

Sharing a sofa or chair with an infant can increase the risk of SIDS by up to 50 times.

Co-sleeping is much more dangerous when parents smoke or have smoked during pregnancy.

The risk of co-sleeping for non-smoking parents mainly affects infants with low birth weight (2.5Kg), infants born pre-term (<37 weeks), and the risk is higher for infants aged under 3 months old.

The risk of SIDS is increased where there is co-sleeping, and a parent has used alcohol or drugs (see Section 6.6, Toddlers).

Recommendations

Practitioners must recognise that many parents choose to co-sleep for a number of reasons, and in some cultures it is common practice. It is also important to recognise that co-sleeping can happen both intentionally and unintentionally. A survey of over 8,500 parents carried out by The Lullaby Trust has shown that 76% have co-slept with their baby at some point. However, over 40% of parents admitted to having done so in dangerous circumstances such as on a sofa, having drunk alcohol or as a smoker. All of these circumstances greatly increase the risk of SIDS. Understanding the family's experiences and circumstances with regards to co-sleeping is important. To tell parents that they should never co-sleep, or to not discuss co-sleeping, is not safe and could increase the risk of baby being put into unsafe co-sleeping situations. Parents should be given advice about safer practices for bed sharing at each routine postnatal contact (NICE 2022):

Babies should be placed on their backs for sleep, in a clear safe space, in the presence of a caregiver day and night;
Parents should be made aware that co-sleeping is associated with an increased risk of SIDS and should be avoided where:
- Either parent smokes;
- Either parent has consumed alcohol or taken drugs (including medications that may make them drowsy);
- The baby was premature;
- The baby was low birthweight.
Co-sleeping on a sofa or armchair is significantly more unsafe than on a bed;
Parents who choose to co-sleep in a bed should be aware of steps they can take to make it safer:
- Keep your baby away from the pillows;
- Make sure your baby cannot fall out of bed or become trapped between the mattress and wall or the gap between a next-to-me crib and the parental mattress;
- Make sure the bedclothes cannot cover your baby's face or head;
- Keep other children and pets out of the bed;
- Don't leave your baby alone in the bed, as even very young babies can wriggle into a dangerous position (UNICEF, 2022);
- The mattress needs to be firm and flat with no dips. An airbed is not a suitable alternative to a bed;
- Breastfeeding mothers tend to adopt the ‘protective C’ position also known as the ‘cuddle curl’ keeping the infant at breast level and preventing her rolling onto the baby.

Co-sleeping when extremely tired

Some safer sleep guidance, including publications by the Lullaby Trust, advise parents not to sleep in the same bed as baby if they are extremely tired. This advice could be potentially confusing for parents, without a clear evidence base. The evidence for not co-sleeping if you take drugs either prescribed or illegal which cause drowsiness is however clear, and is supported by the UNICEF message that co-sleeping deaths could be reduced 90% if no baby slept in hazardous situations. See Section 4, Current Evidence-Based Information to be Provided to All Babies Carers.

Resources

6.4 Temperature and Overwrapping

Babies are at increased risk of SIDS when they get too hot– this can cause thermal stress in the infant caused by high room temperature, outdoor temperature, or thermal insulation from excessive overwrapping or both. Overwrapping can be due to clothing and bedding, the prone position, bed-sharing, and head covering (Bach and Libert 2022)

Wearing hats or outdoor clothing for sleep during the day or night can increase baby's risk of SIDS.

Recommendations

Babies should not wear hats indoors or when asleep;
Babies should be checked to ensure that they are a suitable temperature, and clothes and bedding are appropriate for the room temperature;
A room temperature of 16-20 degrees centigrade is suggested;
Hats and outdoor clothing such as snowsuits should be removed when your baby is in the car.

Resources

The Lullaby Trust, The safest room temperature for babies.

Swaddling and Slings

The evidence for swaddling and SIDS is unclear and further research is needed. However, Babies that are swaddled may sleep more deeply putting them at higher risk of SIDS. The ability to arouse (begin to wake) from sleep is key to a baby’s ability to cope with things in their environment that might otherwise put them at risk of SIDS. Parents/carers who wish to swaddle their baby should seek advice on how to do this correctly. The latest advice on swaddling is as follows:

If you decide to adopt swaddling, this should be done for each day and night time sleep as part of a regular routine:

Use thin materials;
Do not swaddle above the shoulders;
Never put a swaddled baby to sleep on their front;
Do not swaddle too tight, particularly around the hips;
Check the baby's temperature to ensure they do not get too hot. Ensure baby is not overdressed and do not use additional blankets;
Stop swaddling when the baby starts to roll.

Slings

(Please see Section 7.4, Slings below for more information on Slings)

Resource:

6.5 Bedding and Mattress

Loose bedding such as quilts, pillows and duvets is associated with an increased risk of SIDS. These items can cause overheating and can cover baby's head resulting in suffocation.

Soft sleep surfaces such as soft mattresses (as opposed to average and firm mattresses), airbeds, and quilts, pillows and sheepskins used as sleep surfaces, are also associated with a significant increase in the risk of SIDS.

Some studies have noted an association between second-hand mattresses and SIDS.

Recommendations

Blankets must not be too thick or doubled over. They must be firmly tucked in and come up no higher than the shoulders;
A baby sleeping bag can be used. It is important that it is the correct tog rating and fits well around the shoulders so that the baby’s head does not slip down into the bag. No extra bedding is needed if using a sleeping bag;
Babies should sleep on a firm, flat mattress that is clean and in a good condition, ideally new. A mattress with a waterproof cover will help parents to keep it clean and dry;
It is important to keep a baby's head uncovered while they are sleeping. Parents should be advised to place their baby on their back in the 'feet to foot' position (with their feet at the bottom of the cot or Moses basket) and the use of pillows, quilts and duvets should be avoided;
The mattress should be well-fitted to the cot with no gaps around the sides. Using a mattress specifically designed for the cot will ensure the best fit;
If a second-hand mattress is used make sure the mattress was previously completely protected by a waterproof cover, with no rips or tears, be in good condition with no water damage, be firm and flat (no areas of sagging) and fit the cot or Moses basket well, with no gaps. It should also have a fire-resistant label on it;
Early Years and Childminder settings may wish to date a mattress so it can be replaced (this should be approximately after 5 years);
The above advice also applies to travel cots.

See also: Section 7, Infant Products on other infant sleep products and surfaces.

Resources

6.6 Toddlers

Once babies are over 12 months of age they are no longer at risk of SIDS, but they do still require a safe sleep space. They can sleep in any position as they do not need to be placed on their back to sleep once they can roll over.

Recommendations

Place cots or toddler beds away from windows and cord blind pulls, curtains or electrical cords due to the risk of strangulation;
They can sleep with a loose blanket and pillow but best to keep large teddies away;
As it is easy for toddlers and young children to become trapped or stuck between the mattress and the wall, situate the head of the bed against the wall. If this is not possible situate the bed tight to the wall or with a gap of no more than 30cm between the side of the bed and the wall.

6.7 Alcohol and Drug Use

Some evidence shows that heavier alcohol consumption and drug-taking, either in pregnancy or after birth, appears to be related to an increased risk of SIDS, although other SIDS risk factors such as smoking, low socioeconomic status, poor antenatal care and low birthweight are often also involved.

As noted above, there is evidence of increased risk of SIDS where there is co-sleeping, and a parent has used alcohol or drugs.

Substance misuse by a parent or carer is widely recognised as one of the factors that puts children more at risk of harm. The biggest risk posed to babies and children is that parents, when under the influence of drugs or alcohol, are unable to keep their child safe (including overlay through co-sleeping).

Failing to follow this advice may constitute a safeguarding concern and require professionals to take further advice on any action which may be required. If there are concerns about significant harm, normal safeguarding procedures and processes apply (see also: Section 9.1, Early Help Assessment).

The evidence on the impact of prescription or over-the-counter medication and SIDS has been reviewed. Most guidelines refer to 'illicit' drugs, though reference is made to any substance which makes a parent drowsy or unresponsive which could create a hazardous co-sleeping situation even if this is legally prescribed medication.

Recommendations

Women have been advised to abstain from drinking alcohol and taking drugs in pregnancy. No 'safe' level of alcohol has been established, so it is advisable for pregnant women to abstain from alcohol completely
Parents should carefully consider infant care arrangements for the whole night if they plan to drink or use drugs recreationally, including avoiding co-sleeping. Parents should be made aware that co-sleeping is associated with an increased risk of SIDS where either parent has consumed alcohol or taken drugs (including medications that may make them drowsy).

Resources

Factors associated with a decreased risk of SIDS

6.8 Antenatal Care

Receiving timely and regular antenatal care is associated with a lower risk of SIDS. All women should receive the recommended number and schedule of appointments during pregnancy.

Receiving adequate antenatal care is especially important for women who have previously lost a baby to SIDS, as they are more likely to experience pregnancy complications such as preterm birth and intrauterine growth restriction in subsequent pregnancies, increasing the risk for recurrent SIDS.

Recommendations

Good communication between agencies if a woman is not engaging with antenatal care to identify babies more at risk and enable a plan of support;
If appropriate refer the family to the Care of next infant (CONI) Programme if it is available and the criteria is met.

Resources

Care of Next Infant (CONI) - The Lullaby Trust.

6.9 Room Sharing

There is a significant decrease in the risk of SIDS when infants are placed in the same room as their parents, but they do not share the same sleep surface.

Recommendations

Parents should be advised that a baby should have a clear safe space to sleep in and for the first six months should sleep in the same room as the parents, day and night.

Resources

The Lullaby Trust, Sharing a room with your baby.

6.10 Breastfeeding

Breastfeeding lowers the risk of SIDS. Breastfeeding for at least 2 months halves the risk of SIDS but the longer baby is breastfed, the more protection it will give baby.

Even breastfeeding for a short time can help reduce the risk of SIDS. Both partial and exclusive breastfeeding have been shown to be associated with a lower SIDS rate, but exclusive breastfeeding was associated with the lowest risk.

Resources

The Lullaby Trust, Breastfeeding and SIDS;
Unicef UK Baby Friendly Initiative - Caring for your baby at night: A health professional's guide.

Breastfeeding support for parents:

NHS.UK, Breastfeeding: the first few days;
UNICEF, Support for Parents;
National Breastfeeding Helpline 0300 100 0212;
Breastfeeding Friend. Sign in with Facebook and message the Start4Life Breastfeeding Friend chatbot for fast, friendly, trusted NHS advice anytime, day or night. Also works with Google Assistant and Amazon Alexa.

6.11 Dummy Use

Some research suggests it is possible that using a dummy when putting a baby down to sleep could reduce the risk of sudden infant death.

Recommendations

Breastfeeding should be established for at least a month before the dummy is introduced. Breastfeeding is a protective factor against SIDS (see Section 6.9, Room Sharing);
Parents could consider offering a dummy when settling the baby to sleep;
If baby uses a dummy as part of their sleep routine it should be given for every sleep, day and night;
Stop giving them the dummy when they're between 6 and 12 months;
Remove any attachments on the dummy;
Never coat the dummy (for example, with something sweet);
Don't force baby to take a dummy or put it back in if baby spits it out;
Don't offer a dummy during awake time.

Resources

The Lullaby Trust, Dummies and SIDS.

6.12 Immunisations

Immunised infants have a significantly lower risk of SIDS.

Recommendations

Parents should be advised to ensure their infant receives all scheduled vaccinations.

Resources

Further information on scheduled vaccinations is in the Personal Child Health Record (or Red Book) given to parents/carers at a child's birth.

Family circumstances associated with SIDS

6.13 Mums Under 20

Babies born to mothers below the age of 20 are nearly four times more likely to die from sudden infant death syndrome (ONS, 2021). Young parents are less likely to attend antenatal classes and more likely to smoke.

The Lullaby Trust provides dedicated support for young parents. See: Little Lullaby.

6.14 Mental Health

Several studies have identified parental mental ill health as a characteristic of families affected by SIDS.

Most research has focused on mothers, but growing evidence suggests that the fathers' mental health is also a factor. Mental health is impacted significantly where abuse of drugs and alcohol are factors. Health care professionals should ensure that families where mental ill health are identified in either partner, in particular women with perinatal depression, are appropriately treated and are provided with clear advice on infant care practices that may prevent SIDS.

The most common mental ill health that women in the perinatal period experience are depression and anxiety.

6.15 Deprived Socioeconomic Background

Alongside the overall reduction in incidence, however, there has been a steady shift towards these tragedies happening predominantly in families from deprived socioeconomic backgrounds (Child Safeguarding Practice Review Panel, July 2020).

The National Child Mortality Database (NCMD) report also emphasised that 42% of unexplained infant deaths (SIDS) occur in the most socioeconomically deprived neighbourhoods (NCMD 2022)

Babies born to mothers who are poor are more likely to be of low birth weight, premature and their mothers are more likely to have poorer access to maternity care and good nutrition

6.16 Overcrowding

A UK case-control study of factors influencing the risk of SIDS found an association between overcrowded housing conditions and co-sleeping among younger infants (Blair et al., 1999). Some non-UK studies have found that social and environmental factors, such as living in overcrowded accommodation, may contribute to infants sleeping on an unsafe surface (British Columbia Coroners Service, 2009) or the lack of a safe infant sleep space (Chu et al., 2015).

6.17 Change in Family Circumstances or Disrupted Routine

A recent review into SUDI in families where the children are considered at risk of significant harm found that disrupted routines were a common theme in SUDI cases and often led to parents not following safer sleep advice, either because they were unable to, or because they did not consider it relevant in the circumstances. Planning for infant safety during disrupted routines might avoid rare but very high scenarios (Child Safeguarding Practice Review Panel, July 2020).

6.18 Temporary Accommodation or Homelessness

The NCMD analysed the deaths of 10,256 children between 1st April 2019 and 31st March 2023 and found temporary accommodation was deemed to be a contributing factor in the deaths of 55 children. Of those 55 children, 42 were less than a year old.

In March 2024, the Department for Levelling Up, Housing and Communities (DLUHC) changed the Homelessness Code of Guidance for councils to encourage the provision of cots. It wrote to all local councils saying they need to “make it explicit that temporary accommodation should not be considered suitable for a family with children under two if there is not enough space for a cot, and that housing authorities should support families to secure a cot where needed (Gov.uk 2024).

6.19 Domestic Abuse and Safeguarding

A qualitative analysis of serious case reviews into unexpected infant deaths found that domestic abuse was common in families with SUDI. Also common were concerns about neglect and established patterns of non-engagement with professionals, with many families already well known to services (Garstang and Sidebotham, 2018).

7. Infant Products

7.1 Car Seats and Other Sitting Devices such as Swings, Gliders, Soothers and Rockers

There is little evidence on car seats and other sitting devices and SIDS. However, data indicates that improper use of such devices can pose a risk of accidental asphyxia or strangulation. A baby's airway (breathing tube) is very delicate and in some situations, it can block, narrow or fold which can make it difficult for them to breathe. Bouncers, swings, beanbags, pods/nests, sleep positioners, pillows, hammocks can have an effect on the baby’s head falling forwards. If the chin is down, then the airway will be restricted. If the head is in alignment, then the airway is open, and baby can breathe. Other sitting devices could include baby bouncer, rocker or swing chairs and pushchairs. In the United States, where there have been over 100 deaths directly attributed to ‘rock and play’ products, the sale of inclined sleepers have been banned under the ‘Safe Sleep for Babies Act’ since 2022 due to their hazardous nature.

Recommendations

Car seats should only be used for transportation and not as an alternative for cots or highchairs or sleeping. Babies cannot breathe as efficiently when they are in a car seat due to the upright position. The general rule of thumb is no longer than 2 hours in a car seat regardless of whether they are stationary or moving, and for babies under 4 weeks of age this time is reduced to 30 minutes before their oxygen saturation becomes compromised. After this timeframe, the journey should be interrupted, and they should be taken out of the car seat and laid flat for a period before the journey continues;
If an infant falls asleep in a car seat or sitting device they should be moved to a flat surface when it is safe to do so;
Car seats and sitting devices should not be placed on high or soft surfaces – they could fall off or topple and cause injury;
When travelling, stop for regular breaks to check on baby, take them out of the car seat and let them stretch and move around;
Any inclined seated product including swings, gliders, soothers and rockers should not be used for infant sleep.

Resources

Car seats and SIDS - The Lullaby Trust.

7.2 Sleep Positioners, Pods, Wedges, Beanbags and Specially Designed Pillows

A sleep positioner is a mat with raised supports or pillows attached to each side, designed to keep babies in specific positions. It is in fact any item to keep the baby in position e.g. a rolled-up towel. Pods or nests are softer types of sleep surface with raised or cushioned areas. Sleep positioners can cause the fatalities they are supposedly designed to prevent and are not recommended. Although no research has been conducted to evaluate whether any such products increase or decrease the risk of SIDS, analysis of consumer safety reports in the US has implicated some products in infant deaths involving suffocation, strangulation and entrapment.

Some sleep positioners are designed to keep baby on their side or prone when sleeping. Placing an infant to sleep on their stomach (prone) or side is significantly associated with an increased risk of SIDS (see above).

It should also be noted that while mattresses have to comply with specific British or European safety standards, sleeping positioners, pods, nests or wedges do not have to comply with these same standards. There is evidence to show that soft sleep surfaces are associated with a significant increase in the risk of SIDS (see above).

Recommendations

New infant sleep products are coming onto the market all the time. Practitioners should encourage parents to sleep baby on a firm, flat mattress to reduce the risk of SIDS and accidents, for every period of sleep;
The sleep space should be kept as clear as possible to reduce the risk of accidental strangulation, suffocation or entrapment;
Sleep positioners should be avoided.

Resources

7.3 Cot Bumpers

Cot bumpers have been implicated in infant deaths and non-fatal child accidents. Infants can become wedged between the bumper and cot mattress, get into a position where their face is pressed up against the soft padding of the bumper, become entangled in the bumper or its ties, or, for older infants, fall from the cot after climbing on the bumper.

Recommendations

Avoid the use of cot bumpers;
An infant's sleep environment should be kept as clear as possible to reduce the risk of accidental strangulation, suffocation or entrapment;
Any charitable organisation providing sleep equipment for families must adhere to this guidance.

7.4 Slings

There is currently a lack of data on the use of baby slings and SIDS, though there have been cases of infant fatalities attributed to sling use and suffocation and/or overwrapping. Younger infants may be particularly at risk. The safest position is an upright one that meets the TICKS guidelines.

Recommendations

The Consortium of UK Sling Manufacturers and Retailers provides the following advice to baby sling wearers: Keep your baby close and keep your baby safe. When you're wearing a sling or carrier, adhere to the T.I.C.K.S acronym:
- Tight;
- In view at all times;
- Close enough to kiss;
- Keep chin off the chest;
- Supported back.

Resources

Baby Sling Safety.

7.5 Infant Sleeping Bags

There have been very few studies that have investigated the use of sleeping bags; however they appear to be at least as safe as sheets and blankets when no other risk factors are present. When well-fitted around the neck and chest they could prevent head-covering and rolling into the prone position (The Lullaby Trust Product Guide).

It is important to ensure babies are not placed in sleeping bags that are too big, and that they could slide down into (Basis).

Resources

The Lullaby Trust, How to choose baby sleeping products.

7.6 Weighted blankets

Weighted blankets first emerged as a tool to help caregivers calm children with sensory processing disorders. The majority of scientific literature supporting the use of weighted blankets comes from studies of school-aged children with autism spectrum disorder and attention deficit hyperactivity disorder. In these populations, studies are mixed about whether they actually improve sleep outcomes.

Weighted swaddles, weighted blankets, weighted sacks and weighted sleeping bags are not recommended for babies under 1 year due to the risk of overheating and head covering.

Several US studies condemn the use of weighted blankets in infants.

Resources

Lullaby Trust Safer sleep in winter - The Lullaby Trust.

8. Related Issues

8.1 Crying

Some carers lose control when baby's crying becomes too much and go on to shake a baby, which can result in severe head trauma. The ICON programme is all about helping people who care for babies to cope with crying. ICON stands for:

I – Infant crying is normal;
C – Comforting methods can help;
O – It's OK to walk away;
N – Never, ever shake a baby.

The ICON program can be delivered by health visitors, midwives and GPs as well as via social media, and is led locally by West Yorkshire ICB.

See: ICON website.

8.2 Illness

Although the exact role of infant infection in SIDS is not well understood, some studies found infants who die from SIDS had recently acquired respiratory infections. It is recommended that medical advice should be sought if a baby shows signs of illness that persist for more than 24 hours. Some useful resources are available to help parents decide when to seek medical help.

8.3 Prop feeding

Propped bottle feeding is when a baby is bottle fed by leaning the bottle against a pillow, blanket or other supporting device, rather than holding the baby and the bottle while feeding. If a baby is prop fed, they may breathe in the liquid and choke, rather than swallow it. Also, if a baby is fed whilst leaning back or lying down, liquid can go down into the lungs rather than the stomach.

The number of babies dying from breathing in or choking on milk is uncertain, but where large amounts of milk have been found in babies who died suddenly, this was thought to be an important part of the cause of death (Iwadate et al, 2001).

Babies should be bottle fed responsively. The baby should be held throughout the feed in a semi-upright position. The carer should observe for signs the baby needs a break and should not force baby to finish a bottle. This will ensure safety, avoid over feeding and make bottle feeding a pleasant experience for baby.

Recommendation

Do not prop feed. Hold baby close in a semi-upright position throughout the feed.

Resources

8.4 Care of Next Infant (CONI)

Parents who have experienced a sudden and unexpected death of a baby often feel anxious when they have another baby. Working with local public healthcare providers Lullaby Trust facilitate a service for bereaved parents.

CONI is available through health visitors, midwives, paediatricians and GPs, but unfortunately CONI is not available everywhere.

Resources

Care of Next Infant (CONI): information for professionals - The Lullaby Trust.

8.5 Unintentional injuries

Unintentional injuries in the home – such as accidental falls, poisoning, burns and scalds, drowning, and fatal sleep accidents caused by suffocation – are a leading cause of death and disability for children under 5 (Public Health England). As with SIDS, children living in families with deprivation and/or adverse circumstances are disproportionately affected.

Please see below resources which aim to support families to keep their children safe from home accidents, through training for practitioners, assessment tools, provision of safety information and equipment.

Resources

RoSPA;
CAPT.

9. Agency Roles and Responsibilities

Each organisation has a role to play in promoting safer sleep. This will be different between organisations with some having a greater role than others. To reduce the risk of further infant deaths we need everyone in contact with families in West Yorkshire to help ensure safer sleep advice is followed.

The Out of Routine Report encouraged a multiagency workforce approach to SUDI prevention and for it not to just be seen as the responsibility of health professionals. By working together, potentially we could reduce deaths from SUDI by almost 90%.

For services working directly with families, this policy recommends that:

Practitioners are aware of this policy, know the key messages and receive safer sleep training;
Safer sleep training is incorporated into the practitioners' training programme and CPD;
Practitioners discuss safer sleeping arrangements with families, and their wider support network, at each opportunity;
Practitioners have access to safer sleep resources that can be used with/given to families;
Safer sleep is incorporated into the appropriate service operational guidance and procedures, or risk assessment tools;
Safer sleep discussions and actions are documented;
Agencies promote safer sleep messages through their communication channels;
For settings where infants are placed to sleep, safer sleep is incorporated into its relevant policies and risk assessments.

The above would apply to:

Midwives;
Health Visitors;
GPs;
Registered Nurses;
Early Help Workers;
Early Years Workers;
Social Workers;
Fostering and Adoption Services;
Childminders;
Nurseries and other Early Years settings;
Family support volunteers or peer supporters;
Police;
Domestic Abuse Workers and Refuge;
Non-Governmental organisations.

There is a current gap in training for the following areas:

Drug and Alcohol services;
Pharmacists;
Mental health;
Housing;
Yorkshire Ambulance Service;
A&E;
Paediatrics and Special Care in Hospitals.

Some services may require specific guidance:

Neonatal nurses. When babies are preterm or very sick, they may be positioned on their front, side or back and aids to support their bodies such as positioners may be used. Neonatal Unit staff discuss safe sleep with parents while their baby is on the Neonatal Unit and also prior to discharge from the Neonatal Unit. These discussions include highlighting the particular risks of co-sleeping when the baby is preterm or low birth weight. Parents should be provided with the Lullaby Trust Safer sleep advice prior to discharge both in paper format and available electronically via a QR code linking to maternity postnatal leaflets webpage.

Fostering and adoption services should be aware of the increased risk of SIDS when a parent has smoked or consumed drugs or alcohol in pregnancy. This should be part of the risk assessment process and discussed with the fostering/adopting family.

Smoking cessation service should be aware of the association between smoking and SIDS, and ensure this is communicated to the family.

Over the border midwifery services will see West Yorkshire residents and therefore should be made aware of this policy. E.g. Lancashire, North Yorkshire, South Yorkshire, East Yorkshire, etc.

Childminders, Foster Carers, Nannies and Nursery Settings - The Lullaby Trust have published a useful Guide for Childminders, Foster Carers, Nannies and Nursery Settings.

Settings must provide suitable deployment during sleep times (NDNA 2023);
Some Early Years settings have updated their policies to wake sleeping babies if they are brought in asleep by their parent.

OFSTED Statutory Sleeping arrangements state:

All sleeping children must be checked at 10-minute intervals;
Parental wishes should be taken into consideration, although staff cannot force a child to sleep, wake or keep a child awake against his or her will. It is important to note that Ofsted regulation states that it is an Early Years Foundation Stage requirement to respect parental wishes, but practitioners will make decisions based on best practice;
Sleeping children must be frequently checked to ensure that they are safe. Being safe includes ensuring that cots and bedding are in good condition and suited to the age of the child, and that babies are placed down to sleep safely in line with the latest government safety guidance: [EYFS Statutory Framework 2021:3.69].

9.1 Early Help Assessment

Where professionals identify concerns that would benefit from early intervention this should be discussed with the parent/legal guardian at the earliest opportunity. Consent should be gained for an Early Help Assessment to be completed with the family. Further information and guidance is available within the 1.1.4 Early Help / Early Support / Early Intervention (proceduresonline.com)

If a child is believed to be at immediate risk of significant harm, safeguarding action should be taken. See Referrals Procedure.

If there are immediate risks to the baby's safety or that of other children in the household, then this must be reported without delay to the Police.

For emergencies use 999. For urgent/immediate reporting use 101.

If professional judgement identifies a significant risk then it is likely that there will be serious or complex needs or Child Protection concerns requiring an immediate referral to Children's Services (see West Yorkshire Consortium Inter Agency Safeguarding and Child Protection Procedures (proceduresonline.com)). Children's Services must hold a Strategy Discussion whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer Significant Harm, whether or not it appears that a criminal offence against a child has been committed.

10. Resources and Links

Every Sleep a Safe Sleep – contact your local area for training

The Lullaby Trust - safer sleep advice and resources.

Consideration should be given where English is not the first language of parents or where parents have any communication difficulties. The Lullaby Trust 'Safer sleep for babies' leaflets are available in many different languages and in picture form.

Basis - Baby sleep info source: resources for parents. Including safer sleep advice for twins, triplets and more.

UNICEF - sleep and night-time resources.

Safer Sleep Week - usually takes place annually in March and is coordinated by The Lullaby Trust. It aims to raise awareness of SIDS and equip parents with information how they can reduce the risk. Resources are made available to support local campaigns.

Baby Buddy App - The Baby Buddy app guides parents through pregnancy and the first 6 months following baby's birth. It is designed to help parents look after baby's mental and physical health.

Safer sleep: West Yorkshire Health & Care Partnership (wypartnership.co.uk)

11. References

Baby Sleep Bags – BASIS

Blair, P., Fleming, P., Young, J., Nadin, P., Berry, P., Golding, J., Smith, I., Platt, M. (1999). Babies sleeping with parents: Case-control study of factors influencing the risk of the sudden infant death syndrome. British Medical Journal vol. 319 (no. 7223), pp. 1457-1461.

Peter S. Blair., Helen L. Ball., James J. McKenna., Lori Feldman-Winter., Kathleen A. Marinelli., Melissa C. Bartick. Bedsharing and Breastfeeding The Academy of Breastfeeding Medicine Protocol #6, Revision 2019.

Child Death Review Unit. (2009). Safe and Sound: A Five-Year Retrospective. Child Deaths in British Columbia. British Columbia Coroners Service.

Child Safeguarding Practice Review Panel. (2020). Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm.

Chu, T., Hackett, M., Kaur, N. (2016). Housing influences among sleep-related infant injury deaths in the USA. Health Promotion International vol. 31 (no. 2), pp. 396-404.

Garstang, J., Sidebotham, P. (2018). Qualitative analysis of serious case reviews into unexpected infant deaths.

GOV: Department for Levelling Up, Housing & Communities: Homelessness code of guidance (publishing.service.gov.uk)

Iwadae, K., Doy, M., Ito, Y. (2001). Screening of milk aspiration in 105 infant death cases by immunostaining with anti-human alpha-lactalbumin antibody. Forensic Science International.

Herbert Renz-Polster., Peter S. Blair., Helen L. Ball., Oskar G. Jenni., Freia De Bock. (2024) Death from Failed Protection? An Evolutionary-Developmental Theory of Sudden Infant Death Syndrome.

National Institute for Health and Care Excellence (NICE) Guidance - Quality statement 5: Safer practices for bed sharing.

NHS Sudden infant death syndrome (SIDS)

Safe sleep in nurseries (ndna.org.uk)

The Lullaby Trust (2019). Evidence Base, March 2019.

The Lullaby Trust. Product Guide, a guide to buying safer sleep essentials.

The Lullaby Trust Safer Sleep for Babies – A Guide for Professionals

The Lullaby Trust - SIDS-Briefing-2022-Yorkshire-and-The-Humber.

UNICEF (2019). Co-sleeping and SIDS: A Guide for Health Professionals.

Co-Sleeping and Bed Sharing — Pros and Cons, Safety for Babies (whattoexpect.com)